Advanced Nursing Practice: Opportunities and Challenges in British Columbia

by Heather Davidson, Rita Schreiber | Mar 31, 2003

Key Implications for Decision Makers

  • British Columbia should foster two advanced nursing practice roles by supporting the "clinical nurse specialist" and establishing the "nurse practitioner."

  • New money should be allocated to health authorities for advanced nursing practice positions and to provide for infrastructure and organizational support of advanced practice nursing.

  • Government and professional associations should fund and develop a public education campaign to educate and market advanced nursing practice roles to the public, policy makers, and other providers.

  • Legislation, regulation, and deployment of advanced practice nurses should not occur in British Columbia unless and until there is stable funding to support implementing and sustaining the role.

  • Employers and nurses in British Columbia identified health promotion, illness prevention, chronic disease management, primary care, mental health, and geriatrics as areas in which advanced practice nurses could be used.

  • In other jurisdictions, physician shortages, gaps in services, and political will were generally associated with the setup of advanced nursing practice roles.

  • Effective advanced nursing practice roles can be established in British Columbia by developing and implementing legislation and regulation that:

    • is consistent with the Canadian Nurses Association framework;

    • protects the titles "nurse practitioner," "clinical nurse specialist," and "advanced nurse practice;" and

    • enables a professional practice model in which practitioners have sole authority for their practice, clear standards of practice, accountability for decision-making, and skill maintenance and development.

Executive Summary

This project supports decision-making and policy development around new and emerging nursing roles and service delivery models within British Columbia. The main project question was "What can registered nurses practising in new and/or advanced roles contribute to health and service delivery needs in British Columbia?"

Registered nurses in British Columbia should be able to practise in two advanced nursing practice roles - "clinical nurse specialist" and "nurse practitioner." Clinical nurse specialists are registered nurses, usually at the graduate level, who demonstrate excellence in a focused area of nursing practice and are role models and advocates for quality healthcare. They also provide leadership and act as clinicians, consultants, educators, and researchers. Nurse practitioners are registered nurses who have achieved the level of education required for additional registration as a nurse practitioner with the Registered Nurses Association of British Columbia. Nurse practitioners' skills are usually learned through graduate nursing education and substantial nursing practice experience. Nurse practitioners provide healthcare services from a holistic nursing perspective combined with a focus on the diagnosis and treatment of acute and chronic illnesses, including prescribing medications.

"The nurse practitioner role greatly benefits doctors' practice because patients need a great deal of support for symptom management and docs are simply not prepared to do it, either in terms of time or up-to-date knowledge."
- radiation oncology physician

Legislation, regulation, and deployment of advanced practice nurses should not occur, however, until stable funding to support implementing and sustaining the advanced nursing practice role is in place. Government and professional associations should fund and develop a public education campaign to educate and market advanced nursing practice roles to the public, policy makers, and other providers. Further, new money should be allocated to health authorities for advanced nursing practice positions and to provide for infrastructure and organizational support of advanced practice nursing, particular skill development, and maintenance needs. New money should be allocated to universities to support development of appropriate educational programs to prepare faculty to teach in these programs and to support continuing education. As well, funding reallocation needs to be explored to support salaried advanced nursing practice. Funding models to support the development and sustainability of advanced nursing practice also needs to be explored.

Legislation and regulation of advanced practice nurses should be set up using a professional practice model in which practitioners have sole authority for their practice, clear standards of practice, accountability for decision-making, and maintaining skills. As well, legislation and regulation should protect the titles "nurse practitioner," "clinical nurse specialist," and "advanced practice nurse." Educational preparation for entering advanced nursing practice should be at the graduate level in nursing appropriate to the competencies required.

Advanced nursing practice is not new to B.C. The research team found that registered nurses in B.C. who were interviewed for this study say they are already practising in an advanced role, although the degree to which their practice was congruent with national standards was variable. Nurses' understanding of their role was related to their level of formal education. The majority of nurses think their knowledge and skills are underused due to limitations on scope of practice, restrictive job descriptions, and/or multiple demands on time. In their opinion, advanced nursing practice could be expanded in health promotion, illness prevention, and chronic disease management with a broad range of population groups, as well as in specific clinical areas such as primary care, mental health, and geriatrics. Almost all nurses included in the study thought advanced nursing practice should require practice experience and formal education, but they differed on the level of formal education they recommended.

"We work really well as nurses first and nurse practitioners second with chronic illness, which nobody likes to manage. We o a good job with that. We help people look, maybe accept, maybe work through, maybe get to a point where they can manage themselves. And we're more patient about it [than physicians]. We take the patient's perspective. So we're probably the better people to be doing that kind of work, in consultation with a physician."
- advanced practice nurse

Employers also endorsed creating advanced nursing practice roles. More than 70 percent of the employers surveyed said they already had nurses in advanced practice roles, and 30 percent said they intended to hire more nurses in such roles in the future. Employers reported a need for clinical nurse specialists, particularly in practice areas where gaps in service were reported, such as primary care, geriatrics, and mental health. Lack of funding was reported as the most common barrier to implementation. Nurse practitioners were seen as most needed in primary care and palliative care. Barriers to implementation included lack of funding, lack of availability of qualified advanced practice nurses in B.C., physician resistance, and restricted scope of practice.

Employers in urban areas placed a higher priority on having clinical nurse specialists in medical and surgical care units and in pediatric care. They also rated the importance of research skills more highly. Employers in rural and remote areas identified public resistance as a bigger barrier to implementation of advanced practice roles than did employers in urban areas.

Other jurisdictions (Ontario in Canada and Washington State in the United States) that have advanced nursing practice roles were studied and models identified. In all sites that were studied, advanced nursing practice roles developed as a result of the union of three factors: physician shortages, gaps in service, and a welcoming political climate. Other providers and patients saw nurses in advanced nursing practice roles as providing good quality care that met patients' needs, and there was a high degree of satisfaction with the care they provided. Nurses in Ontario and Washington who are licensed and recognized as advanced practice nurses were more congruent than B.C.'s nurses in their understanding of advanced nursing practice, although the latter function as but are not yet licensed or recognized as advanced practice nurses.

"To me, I think you're bringing a composite of nursing care, nursing skills, together with a happy blend of what I would call global care, holistic care to the patient, which takes in both the nursing and the medical aspects into a single whole. They bring to the role the whole background and philosophy in terms of nursing and certainly the sensitivity and caring that goes along with nursing, the nursing skill and then, in fact, blend that into the medical care of the babies by performing a very essential role in terms of composite, if you like, total family-centred care... It's very different for the physician, I think..."
- neo-natal physician

In order to develop these findings and recommendations, the project was conducted in three phases. In Phase 1, we studied what the current status, understanding, and need for advanced nursing practice roles in B.C. are. Nurses who identified themselves as clinical nurse specialists provided their opinions through e-mail and telephone surveys and focus groups. Employers' opinions were gathered through e-mail surveys. In Phase 2, we explored "what could be" by conducting case studies of six models of advanced nursing practice in five sites in Ontario and Washington. In Phase 3, we defined in some detail "what should be," related to advanced nursing practice in B.C. To develop this vision, nurses, physicians, other providers, employers, researchers, policy makers, educators, and representatives of professional organizations participated in a two-day think tank.

Additional research should be conducted on evaluating the implementation of nurse practitioners within B.C. Further, the feasibility of adopting nurse anaesthesia as an advanced nursing practice role in Canada should be explored.